How Will Health Care Decision Affect Doctors?

I'm Michel Martin and this is TELL ME MORE from NPR News. Coming up, Leo Manzano came from behind to win the 1500 meters track and field national championship last night and with it he booked his place on the U.S. Olympic team. We'll hear how Manzano went from living in a Mexican village with no running water to running for the red, white and blue.

But first, we want to talk again about the Obama administration's health care initiative, the Affordable Care Act, given new life last week after the Supreme Court upheld most of the provisions. So we thought this would be a good time to check in with some of the people most affected by the changes along with patients, of course. That would be doctors.

So we've called Dr. David Ellington. He is a family physician in Lexington, Virginia. He sees patients who have private insurance and in a clinic practice who do not. We've talked with him several times as the health care act was being debated. He's with us once again on the line from Virginia. Dr. Ellington, thanks so much for joining us once again.

DR. DAVID ELLINGTON: And thank you for asking me back, Michel.

MARTIN: Also with us, congresswoman Donna Christensen. She is a Democrat representing the Virgin Islands in the U.S. Congress and she is also a board-certified family physician and she spent much of her career in Congress working on health care issues, and she's with us from the Virgin Islands. Congresswoman Christensen, thank you so much for joining us once again.

REP. DONNA CHRISTENSEN: Thank you. My pleasure.

MARTIN: And also with us Dr. Lawrence Johnson. He is a pathologist and he joins us from KWGS in Tulsa, Oklahoma. Dr. Johnson, thank you for joining us as well.

DR. LAWRENCE JOHNSON: Thank you for having me.

MARTIN: Dr. Ellington, I'm going to start with you because, as we mentioned, we checked in with you from time to time as the law was being debated. We wanted to know, first of all, whether this debate over the Affordable Care Act, whether the uncertainty over it affected your practice in any way, or the patients that you were dealing with and their kind of thoughts about health care in any way?

And of course I wanted to know what are your thoughts now that this argument seems to have been concluded, at least for now.

ELLINGTON: It did affect my patients in that there were a number of patients, especially those who had children, who were now out of college and were having trouble getting employment or health insurance through their employment, it gave them the opportunity to have some hope.

It's caused quite a bit of - I won't say unrest, but questions at our free clinic, as we have tried to figure out what will be the impact upon this and we're actually undergoing a rather significant planning process right now and may be moving to a federally qualified health center-type approach from just the free clinic approach in order to meet the need in Rockbridge County.

We're a rural county in the southern part of Shenandoah Valley and we have probably about 30 percent of people would who be eligible and right now we just don't have the infrastructure and capacitance in the area to take care of those folks if they suddenly had insurance. And so I think that is one of the big concerns.

The concern is not that the program is not going to provide the insurance, but what will be the medical capacitance to take care of it.

MARTIN: Mm-hmm. Dr. Johnson, what about you? I take it you're skeptical of this law and the benefits of this law.

JOHNSON: I think that the law has been good in the sense that it's forced people to focus on the issue whereas previously they have not. I am skeptical because I also see patients because I'm also a hematopathologist so I perform bone marrows and I diagnose the (unintelligible) lymphomas clotting disorders. So I do have a clinical component to my practice. But unfortunately, I think the law still failed the three fundamental tests: cost, quality and access.

And those are concerning to me because I think we're taking a bad situation and making it worse.

MARTIN: Give me an example of what you're concerned about there.

JOHNSON: Well, in terms of cost, for example, the U.S. government is terrible at estimating Medicare. The House Ways and Means Committee estimated in 1990 the cost would be $12 billion. It's, what, $120 billions? So the government is poor at estimating cost. My own premiums, for example, have doubled this year.

Part of that is because of the mandates that have been placed on insurance policies. Now, people are having mandates for programs like in vitro fertilization, breast reduction and so forth, where they previously didn't want it. So the insurance companies are forced to scale that into their costs. So premiums go up.

The other thing is because insurance companies cannot charge people with preexisting conditions. The average cost or premium, again, goes up because of that.

MARTIN: Mm-hmm.

JOHNSON: So you have cost shifting. And then of course high deductible plans and plans with health savings expense accounts are going to be reduced, which I have, and, again, my premiums go up. So the cost is an issue. And in terms of quality, I'm concerned because you're going to have rationing, and that's already happened as of 2009.

The U.S. Preventive taskforce made a recommendation to reduce - or actually - to get rid of mammograms altogether in women in their 40s. And this was based on cost. That, again, is an example of rationing and that's built into the plan because we have what's called comparative effectiveness research and they use it to ration, not based on medical effectiveness, but cost effectiveness.

And they are very different issues. And then finally, is access to the poor. Medicaid has been - essentially that part of the program has been gutted, and that was the major point of expansion of this program, was to expand it to the poor. And that's gone. And we had 26 states that sued the U.S. government and got that reversed.

MARTIN: Hmm.

JOHNSON: And then those that do get Medicaid, we already know that they do worse health-wise than those that have Medicare or private insurance. And so I think the law has failed on those three fundamental issues.

MARTIN: OK. And if you're just joining us you're listening to TELL ME MORE from NPR News. I'm Michel Martin and we're speaking with a roundtable of doctors about the Affordable Care Act. We just heard from Dr. Lawrence Johnson. He's a pathologist and practicing in Oklahoma and Dr. David Ellington, a family physician in Virginia.

Now, we're going to hear from delegate Donna Christensen. She's also a board-certified family physician. Well, what about that, Dr. Christensen? You just heard two different views.

CHRISTENSEN: Yeah.

MARTIN: You've got one doctor very much looking forward to the benefits of this, thinking this is really going to improve health care for a lot of the patients that he sees on a regular basis, and somebody who's very skeptical.

CHRISTENSEN: Yes. There were a lot of issues raised just then and on, I guess, Dr. Ellington's is easier to just deal with because I totally agree; the ability to keep your young people on until 26, the expansion in community health centers will help a lot of communities. And we do have concerns about being able to build the kind of health care workforce that will be required to meet the needs of the new 30-odd, 32 or so million people who will be covered.

And we do have provisions in the act to expand on National Health Service Corps, to expand on loan forgiveness programs, and to also support the training of under-represented minorities as we expand that workforce. On some of the other issues, we're not really good at estimating costs because we also don't count the savings.

We tried over and over again to have the Congressional Budget Office score the savings that might come about because of some of the provisions, especially on the prevention side in the health care and the Affordable Care Act. Another doctor, Dr. Mike Burgess, a Republican, and I have introduced legislation to have CBO begin to score prevention.

So while we don't score and sometimes it's over, the amount that we project, it may be under because of prevention. And quality - and let's go to cost for a minute. Remember that now many more people will be insured. Many healthy people will be insured and that should begin to lower the cost.

In addition to that, the Secretary's already used the authority granted to her in the act to review premium increases and has been able to keep them below the 10 percent in, I think, about 12 states, to lower those premiums from what was projected by the insurance company.

MARTIN: I think I would take issue with one thing that Dr. Johnson said about - well, two things about rationing because I think that, you know tens of millions of people who don't have health care now would argue that they're already being rationed in a certain way.

CHRISTENSEN: They are. There is a two-tiered system in this country, at least, and...

MARTIN: But to his point, though, that if you - kind of taking it to its simplest level, I think what he's saying is it's going to be a mess. But at the very least I think both of your colleagues are saying that it's going to be a mess in the near-term. Dr. Christensen, do you think that that might be true?

CHRISTENSEN: We're implementing major change here. So it is going to be difficult and I think that's the benefit of doing it gradually over the three or four years that we put in place to do the implementation. I do share Dr. Johnson's concern, though, about Medicaid and the way the ruling came down on Medicaid. I would hope that many of the states would reconsider denying their residents the benefits of Medicaid, where for the first few years 100 percent of it is paid by the federal government and it goes down to about 90 over the next couple of years.

CHRISTENSEN: So I would hope that maybe state legislators - where we can work with some of the people who would be supporting it in the state legislatures to try to make sure that states would accept the Medicaid expansion, because it will make a big difference, and that's where some of the savings - getting everyone covered, getting everyone into funded preventive care and better health maintenance, will - it's what's going to reduce the cost to this country for health care over the long term.

MARTIN: Each of you has identified things that you're worried about and things that you are hopeful about. I wonder if I could get each of you to just expand a little bit more on that, what - in the near term, particularly as it relates to your own practice and the work that you do yourself. And maybe, Dr. Ellington, I'll get you to start. What are you most hopeful about? What are you most worried about, just in the near term, just thinking about the work that you do?

ELLINGTON: I'm most hopeful that we are going to be able to take care of those who don't have care right now, and I'm most fearful of - if the rules are written for the implementation that make it more difficult for you to see patients - in other words, you know, Medicaid, as everyone knows, is the lowest payer out there, so I have a saying in my office, I said the plan that pays the least should be the administratively easiest to do, and my fear is, if you attach too many rules, regulations, oversight to the Medicaid that makes it terribly troublesome, that people are just going to not accept Medicaid.

I just want to bring up one thing, though, and this is more global than local. The Commonwealth Fund, which is a nonpartisan organization, in 2004, '07 and '10 ranked seven countries in the world on quality, cost, access, efficiency, equity. In these seven countries are the Netherlands, the U.K., Australia, Germany, New Zealand, Canada and the United States, and each time they rank them, the United States has ranked dead last, and despite that our costs are over twice what the closest person is.

So you know, if we have concerns about cost, quality and access, then we ought to look at the one single thing that separates our system from their systems, and that is universal health insurance coverage. And to me this is the start of a long process that we're going to go through. Is it going to be a mess in the next couple of years? Absolutely. But it's a mess right now and it's a step we need to take. It just says so much about what kind of nation are we that we won't take care of our own.

MARTIN: We need to take a short break with our roundtable of doctors. When we come back, we'll have a final word from each of them. Please stay with us. This is TELL ME MORE from NPR News. I'm Michel Martin. Transcript provided by NPR, Copyright NPR.